Random Thoughts from a Restless Mind

This weekend was spent in Chicago at the annual meeting of men and women with whom I share my day job. As I noted in “Sunday musings…” I’ve been suffering a bit from some sort of degenerative issue in my hip. Traversing the longest indoor “bridge” outside of the Providence airport rental car connector, my discomfort made me think of my Dad and the back pain that grew to consume him as he aged. Mind you, my discomfort is minimal in comparison, and my particular problem is quite amenable to a surgical fix with a high success rate. Still, it made me feel older, and it made me think of my Dad, gone these 3 years.

Below is what I wrote some years ago when I started to notice the changes in Dad.

When did my Dad get so small? Close your eyes. Think of your Dad. What does he look like? How old is he with your eyes closed? He’s younger, isn’t he? And bigger. MUCH bigger.

I spend most of every day in the company of people decades my senior. I’ve watched some of them age over 20 years or so. There are a few with whom I’ve bonded, who I remember and can conjure up an image if asked. I never appreciate the change in size in them, though.

It’s a strange phenomenon. It’s uncomfortable, no? There really IS a physical change that occurs as we age; we really DO shrink physically. No, it’s more than that when you look at your Dad, more than the physical decrease in size, the loss of vigor and all that goes along with it, the stuff I might actually notice in my patients. What makes it so striking when it’s your Dad is that it’s more than just physical, but a diminution in all dimensions and domains including the one inside your head.

He WAS strength when I was a kid. Literally, a rock. Immovable and unshakeable at all times. Unmoved by excuses or explanations when he knew he was right, or if he MIGHT be right. The final arbiter of discipline (“wait ’til your FATHER gets home…”) in a very traditional family, every thing about the guy was just huge.

When did he get so small? It’s almost scary, you know. He was the guy who stood between me and everything that might be dangerous, at least figuratively. At least in my mind. It’s hard to reconcile the guy I just put on a plane back to RI with my Mom, and the guy who’s there–right in front of me–when I close my eyes. So small now, almost frail. That classic love/fear thing now replaced with something more like love/protect. Does he see it, too? How small?

Will I see it, when I’ve become small?

Sunday musings…

1) Feral. Abbie the Wonder Dog was feral for the first 6 or 9 months of her life. I can’t remember exactly. She was live-trapped and rehabilitated by a Border Collie rescue organization in north central Ohio. When she frustrates me it is always helpful to remember this.

Having a formerly feral creature living in our midst is also a very good counter to the frustrations of modern life. I try to remember how far I am from true privation whenever I find myself railing agains the insanity and inherent indifference that the world clearly has toward my existence.

A quick thought of my clever (read: sneaky) pup is usually all it takes to quell my urge to explode when I encounter the tragedy of a poor internet connection…while hurtling through a mountain pass in a car going 80 MPH.

2) Test. Some 10 years ago or so I proposed that a true measurement of health should be possible. Something that combined the most basic of classic medical knowledge (weight, %BW fat, BP, Cholesterol, etc.) and the breakthrough notion that physical fitness could be measured and tracked. My theory included the necessity of including some sort of measurement of “well-being”, a mandate that was initially openly mocked but seems to have been rather meekly accepted as both logical and necessary.

Creation and launch of such a value, call it “Total Health” or something along that line, has fizzled due to the lack of consensus–nay, even interest–in coming up with a way to measure Fitness. Imagine, in a place like CrossFit where the very definition of Fitness was created, no one save me and a tiny group of equal obsessives has so much as let fly a tiny trial balloon. The original owners of CrossFit LA were the first to use a standard entry test. 500M Row/40 Squats/30 Sit-Ups/20 Push-Ups/10 Pull-ups. I suggested pulling from both traditional sources (The President’s Fitness Test) as well as CrossFit and the larger endurance communities: 2:00 each of PU/Push-Up/Sit-Up/Squat, 1RM Deadlift, 1 mile Run. We ran a competition once called the “Fittest Eye Doc” using this.

What is necessary is a test that is a) doable by the general public, and b) capable of creating a single value that can be measured and tracked. Once that is done mathematicians and statisticians can be let loose with the various factors and given the task of coming up with a formula that includes all three categories. Why bring this here, again, when thus far my previous dozen or so postings have been met with crickets? With the pivot to health and the rapid build-up of a cadre of physicians who are at least superficially interested in using high intensity exercise for the purpose of increasing health, I am hopeful of a broader dialogue that comes to an agreement on a test.

Challenge: create a test of fitness that is broadly accessible in all ways (scalable) that can be included in a definition of health. 3-2-1…Go.

3) Volunteerism. Ladies and gentlemen, we are gathered here today to mourn the death of the Age of Volunteerism. While there exist tiny spaces where true volunteers live and thrive in a bilateral exchange of freely given goodwill, by and large volunteerism has been extinguished by its historical recipients. Today marks my last day ever of hospital ER call, the end of 2 years of receiving token payment for making my expertise available following 25 years of doing so for free. My experience is typical, as is this denouement.

Once upon a time all of your doctors were in private practice. We all had tiny little cottage businesses, did our work, and billed you or your insurance company for the work we did. Some of us worked in tiny little groups, but it was the rare doctor who was part of a large group or business whether in a big city or out in the country. Even the slickest Madison Avenue internist was basically a country doc, just with a better, more expensive wardrobe. In addition to having a greater familiarity with our patients we also enjoyed a very clubby relationship with all of the other doctors where we practiced. There was a collegiality, a sense that we were all in the struggle together. Folks who shirked their duties, foisting them off on other docs, were quickly educated about proper protocol or left alone.

Hospitals were different, too. Local or regional, they were hardly the gargantuan mega-businesses they’ve become. The org chart was shallow, and most local doctors were on a first name basis with the few administrators on the hospital payroll. You took call for the ER as a volunteer; the ER respected that you were donating your skill and your time and handled everything it could before calling you. Same thing for consultations. Your colleague only called you if they couldn’t figure out a problem or ran out beyond their scope of practice. There was a faint air of apology with each request, and a definite unspoken appreciation for the help that would be given. You helped because you were appreciated.

This is really no different from all manner of volunteerism in America. Smallish, closely knit organizations depending on the goodwill and generosity of members of their community pitching in to ensure success. Think local memorial 5K races, or CrossFit Games Regionals in the days before ESPN or the Home Depot Center. Countless small private schools that depended on the largesse and time offered by the families who sent their children there. You gladly accepted the opportunity to volunteer because you knew that without you the organization would not be able to function. You also knew that the recipient of your generosity not only appreciated your contribution, they really had no other options. Not only that, but if that organization somehow existed in your professional space you knew that it would never, not ever, abuse the trust necessary for volunteers to continue.

What happened? Money. Money and size and the distance that they create between an organization and its volunteers. Let’s go back to the hospital and the ER for a minute. Where once your efforts as a volunteer were deeply appreciated and those efforts rewarded with respect and care for your time and your expertise, the growth of employment of doctors by hospitals opened a gap between colleagues. No longer was there the esprit de corps, the shared notion that the primary target of our efforts was the patient was replaced by so very many doctors by the reality that they worked first for a business as faceless and uncaring as GM. Work that was once done by your colleague was now pushed to the volunteers whenever possible. Worse, boxes to be checked by the employed (to maximize revenue and minimize risk) meant demands made of volunteers, not requests. Worse, still, were discoveries that some “volunteers” were more equal than others: they were paid.

While this is nothing short of tragic in health care, it was inevitable once medical businesses were incentivized to grow ever larger. It is not confined to health care by any means. How do you think that volunteer at a Spartan Race feels when he learns how much his “team leader” is being paid? Have you ever “discovered” how much the Executive VP of your favorite professional organization is paid? As a people we Americans are generous to a fault. That generosity usually continues right up until we discover that we have been duped, and even worse that we have been purposely duped by the people who run the organizations for which we volunteer.

And so we gather here to mourn the passing of the Age of Volunteerism. Like so many things of wonder and goodness there remain pockets of resistance, little oases where the goodwill, honesty, and appreciation beget the kind of ebb and flow that made things so much better, kinder, more collegial at the apex of Volunteerism. My friend Tom Gardner was just named the president of the Society of Alumni of our Alma Mater. Tom has given tirelessly of his “spaces”, his timespace, brainspace and emotionalspace to help shepherd tiny Williams College as it flows on though time. Is this truly different? A tiny refuge from the Zombie Apocalypse of corporatization of all things to which we once volunteered?

We can only hope. Hope that Tom and those like him who continue to find places and causes where their volunteerism is met with what we in medicine have had to bid farewell. We can only hope that there will be places where being a volunteer means receiving the respect and appreciation and even a kind of love in return for what we have given. We can only hope that there will continue to be places where the incessant drive to grow ever bigger, size measured on a spreadsheet rather than by heart, will be resisted. For if it can happen in medicine, if volunteerism can be killed in what is arguably the most noble of all endeavors, I fear that it is doomed everywhere.

And so we mourn the end of the Age of Volunteerism. We wait with equal parts sadness and fear for arrival of what follows.

I’ll see you next week…

–bingo

Old. Yup. “The Heir” turns 26 today. “Lovely Daughter” is 24 and my doppelgänger “Lil’bingo” is 22. My body is screaming from yesterday’s CrossFit WOD–I ran a mile. I’m answering emails and questions from CrossFit friends about CF in the “Master’s” category. I am closer to 55 than 54, closer in age to my cataract patients than my school-age patients. My Dad had a quadruple bypass at 54. Old.

How do you do this “old thing” anyway? It seems I don’t have an owner’s manual for myself, just like I didn’t have an owner’s manual for the kids. What am I to expect now? What is it that lies just ahead, and what then beyond that? Is this muscle soreness a freak thing, the anomaly, or is it a harbinger of things to come? How about fitness gains? I’m now 9 years into my CrossFit journey. How much longer can I expect to achieve PR’s? As I contemplate these questions how far forward should I allow my gaze to roam?

There are no answers to those questions, of course. Any answers only lead to the next set of the same. To look too far beyond a couple of tomorrows is as dangerous as it is to look back beyond a couple of yesterdays. Looking behind even a little bit risks the indulgence of regret, what has always seemed to me to be a sure recipe for sadness. I have written elsewhere that to go even further back, beyond Creation or the Primordial Soup or the Big Bang is an invitation to madness.

To look too far into the future is to invite desire, to risk the creation of wants that grow into something that feels like need. If or when these fail to materialize a different type of sadness arises, this one born of resentment. If one projects these too far into the future, to retirement, to rest, to redemption and beyond, the risk of madness can arise once again.

I surely do not know the answer to the question of how to age well. There is no map for the journey that lies ahead, no cosmic GPS. I have only the strategies that have served me thus far, and the hope that they will serve me yet. I have faith, and that faith allows me to resist the temptation to look either too far behind or too far ahead. Faith is the vaccine against madness.

And I am happy. I realized it once again in a phone call with a dear friend, met through Crossfit, and once again when I said goodnight to my darling Beth last night. I am happy because I have very little desire and even less regret; I want what I have and this inoculates me against both resentment and regret.

Yes, indeed, I am older, but I have at least one more today. That’s just what I wanted.

Man, turning 50 has not been an easy proposition. I’ve been turning 50 since the day after my 49th birthday and quite frankly I haven’t been doing such a great job of it. The highway between mile markers 49 and 50 seems to be strewn with all manner of psychological speed bumps and potholes, pretty much all of which I’ve placed there myself.

Why is this? Why so much angst about 50? I didn’t really have any issues with 18, 21, 30, or 40, at least not any that I was so keenly aware of. In fact, I don’t recall ever thinking about the process of TURNING any of those milestone ages, not a minute spent thinking about the run-up to any of those birthdays. I suppose 40 might have presented an opportunity for at least a little introspection, or at least a little taking stock, but “turning40” angst was preempted in the course of a single ride on a chair lift in Utah the week prior to my 40th birthday. My chair-mate, noting his own near existential angst at the prospect of turning 40 several years prior shared the wisdom a priest friend had offered. 40 is when your still healthy, strong, and vibrant body meets the experience and wisdom of your now mature mind. That worked for me! 40 made sense after that.

In a dazzling display of prescience and foreshadowing, my lovely bride Beth responded to my epiphany with “wait ’til he turns 50! That’s gonna be a problem!” Shortly thereafter she contracted the mother of all cases of pneumonia and tried to die on me. Any little bit of an issue with turning 40 got pretty much short circuited in the elation that accompanied her recovery.

And yet, here I am. Turning 50.

What’s the big deal you ask? It’s just a number. You’re a January baby. It’s nothing more than another calendar to throw out.  One more tax return. What’s the problem here? Aren’t you the guy always looking forward, wanting what you have? The “no regrets” guy? Cut the crap! Find your balls. Snap out of it.

To which I respond: sure! There you are going all left-brain/left nut on me. Trying to impose logic and rational thought on what is clearly a right-brain, visceral “feel” kinda thing. It’s all about the right nut, the squishy can’t get your hands around it illogical nonsensical unease that resists both explanation and resolution.

My own left-brain gets it. Hari, one of my Crossfit buddies, nailed the rational aspect of turning 50. According to Hari our first 50 years are all about preparing. We spend our lives preparing either ourselves or someone else for something that is yet to come. We grow and get ready for kindergarten, so that we can prepare for grade school. Grade school begets junior high where we get ready for high school. High school prepares us for college which leads to job and adulthood. We then transition to the task of preparing others, our children, and spend the next however many years engrossed and engulfed in that pursuit. 50 is when we are done with the preparing. 50 is when we we exit Route Preparation and begin our journey on Route Me. At 50 we can learn for the sake of learning, not because we need to knock off a pre-req. We exercise and eat for the here and now, for how we are hoping to feel right at the moment. The first 50 years are about preparing; the next 50 are about living.

Why then, if I get that, am I having so much trouble TURNING 50?

As I’m sure you’ve gathered if you’re spending any time here on Random Thoughts, I am a physician by day. I finally think I figured it out one day in the office when one of my patients mentioned that she was having some issues with turning 60. We took a little detour, talked a little while about our “turning” issues rather than her eyes. 60 meant “old” to her, and old was more than a little frightening. She didn’t see “old” in the mirror, and didn’t want to think about any part of “old”. Her tactic? Classic–She simply decided that she was younger and told everyone she’s  55! How about me, she asked. You’ve made it. Successful practice and a wonderful professional reputation, healthy family, a marriage to be envied. Your biggest problem should be deciding how to celebrate! How will you mark this milestone, this success?

And there you have it. There, in that lovely compliment from a patient I barely know, was the issue. How indeed would I mark this milestone? The cartoonist would have put an enormous light bulb over my head, for here was at once the solution and the problem. I couldn’t say how I was going to celebrate turning 50 because I can’t celebrate in the way that it turns out I always thought I would, and that fact lies at the base of all of my angst, all of my discomfort, all of my difficulty in turning 50.

Physicians play a game early in their lives called “delayed gratification”, a game in which they willingly put up with the hardships of training and postpone most of the trappings of success. Tiny apartments and old clunker cars are OK because there is a world of plenty just over the horizon, a reward for both the sacrifice and the success that students of medicine encounter on their journey. Their preparation, as Hari would say. Once out in the real world, out of medical school and finished with residencies and fellowships, both the willingness and the ability to play “delayed gratification” slip away to be replaced by a sense of pride in having played,  not terribly fond memories incentive to never play again.

There’s the rub–I am once again playing “delayed gratification” and I simply can’t even consider doing some of the things I thought I could think about to mark this milestone. You know, classic 50 year old dumb guy birthday stuff like, I dunno, buying a Porsche. I don’t think I’d actually do that, but I DID always think that at 50 I would have been able to decide NOT to buy a Porsche, even though I could have if I really wanted to. Even the more meaningful stuff I’ve talked about to mark turning 50, stuff like climbing Kilimanjaro with my sons or accepting that invitation from Geoff Tabin to teach native surgeons how to do cataract surgery in Nepal, I’m not going to do those things because I CAN’T, because I am once again playing the game of “delayed gratification”. I might never have done any of those things, or any of a number of other things I might have thought of, but I always thought I’d be able to decide, that I COULD if I wanted to.

I can’t, and I find that I resent that. It makes my sad, and both of these feelings make my left-brain more than a little unsettled, for there is no rational response. No solution. No pithy sentence to conclude this particular Random Thought on an up note. At the end of the day there will be nothing other than sucking it up, moving on, and getting over it, getting over myself. There will be nothing other than trying to play the game of “delayed gratification” just as well at 50 as I did as a much younger man, for in the end I really have no other rational choice. I will have to hope, to try to be much better at BEING 50 than I have been at TURNING 50.

Because I’ve really sucked at turning 50.